Laserfiche WebLink
FOR SERVICE CALL: SERVICE ORDER <br /> DWON OFFICE FORM NO.AES004-B(REV 10W) <br /> 1-800-7-ASBURY SERVICE ORDER NO, <br /> UNION CiTY OFFICE <br /> 1-888-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> H 1-310-886-3400 <br /> TRANSPORTER EPA#CAD028277036 <br /> D F2"R V:f+'F" <br /> 9 62 1 WMA <br /> CUSTOMER# PURCHASE ORDER# ROUTE It TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> X LTC <br /> g� y pp .. .v 1�1•. �t <br /> 1'IF„� 1. �, f '::� � x�Far'`;i )��: I•tr �'a ��I��;.f��- �''�.F•' f i�t.'r8."t I'1 s�4#. <br /> i <br /> TOTAL <br /> CASHREC'D: CHECK# PLEASE PAY FROM THIS SERVECE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OiLIMIXED OILS)"NO PLACARDS REQUIRED* STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS)"NO PLACARDS REQUIRED" STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City,CA 94587 (510)487-9277 <br /> 0 <br /> DRUMS PIU: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to certify that the waste described above is properly classified,described,packaged,marked and labeted,.and is in proper condition for transportation,according to applicable State <br /> and federal regulations.By signing below 1 also hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 0 a1)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,000 ppm,and the waste does not contain any?CBs.I have <br /> complied with the requirements of the applicable California used oil management regulations to determine this Is true.I agree to accept the additional charges for the disposal of this waste <br /> if the information I have provided about this waste is incorrect <br /> 0#2)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATER.than 1,000 ppm,and the waste does not contain any PCBs.I <br /> have provided proper documentation to Asbury Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the additional charges <br /> for the disposal of this waste it the information I have provided about this waste is incorrect <br /> 0 if3)This waste is from a tank which collects waste oil from household"do-it-yourselr'(DIY)andfor conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY!CESQG collection tank is coley from DIY and/or CESOG sources.I have not mixed this waste oil with any other hazardous waste or <br /> waste oil from other sources.I agree to accept the additional charges for disposal of this waste if the information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> 0 ik4) If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and <br /> the environment;Or,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is available <br /> to me that I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />